Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?
A. “My feet look reddish when I put them down.”.
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
B. “I noticed that the hair on my feet and legs is gone.”.
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
C. “My legs were so cold I had to put a heating pad on them.”.
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
D. “My legs start to hurt when I walk to get my mail.”.
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow. However, this symptom does not require immediate intervention but should be evaluated further.
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Full Explanation
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.
Similar Questions
The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes.
Which statement made by the client indicates that the teaching has been effective?
A. “I will always carry glucose tablets or gels to treat episodes of hypoglycemia.”.
Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar. Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.
B. “I will take my medications first thing in the morning on an empty stomach.”.
Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.
C. “I should drink 6 oz. of orange soda if I feel nervous, sweaty, and lightheaded.”.
Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.
D. “These medications help with the release of insulin so I have to start taking shots.”.
This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.
Full Explanation
Choice A rationale
Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar.
Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.
Choice B rationale
Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.
Choice C rationale
Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.
Choice D rationale
This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.
The nurse is monitoring a client receiving gentamicin.
Which of the following would the nurse assess as potential toxic effects of this medication?
A. Pseudomembranous colitis and crystalluria.
Pseudomembranous colitis and crystalluria are not typically associated with gentamicin use.
B. Headaches, vertigo, and tinnitus.
Gentamicin can cause ototoxicity, which can manifest as tinnitus (ringing in the ears), vertigo (a sensation of spinning), and hearing loss. Headaches can also occur as a side effect of gentamicin.
C. Headache and potassium 3.5 mg/dL.
While gentamicin can cause nephrotoxicity (kidney damage), which could potentially affect electrolyte levels, a potassium level of 3.5 mg/dL is within the normal range. Therefore, this would not typically be assessed as a toxic effect of gentamicin.
D. Hypoglycemia and cardiac dysrhythmias.
Hypoglycemia and cardiac dysrhythmias are not typically associated with gentamicin use.
Full Explanation
Choice A rationale
Pseudomembranous colitis and crystalluria are not typically associated with gentamicin use.
Choice B rationale
Gentamicin can cause ototoxicity, which can manifest as tinnitus (ringing in the ears), vertigo (a sensation of spinning), and hearing loss. Headaches can also occur as a side effect of gentamicin.
Choice C rationale
While gentamicin can cause nephrotoxicity (kidney damage), which could potentially affect electrolyte levels, a potassium level of 3.5 mg/dL is within the normal range. Therefore, this would not typically be assessed as a toxic effect of gentamicin.
Choice D rationale
Hypoglycemia and cardiac dysrhythmias are not typically associated with gentamicin use.
A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg.
Which physician’s order should the nurse implement?
A. Administer morphine 2-4 mg IV prn for pain.
After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery.
B. Apply a figure of 8 pressure dressing starting day two post-operatively.
Applying a figure of 8 pressure dressing starting day two post-operativelyis not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
C. Administer antibiotics as prescribed.
Administering antibiotics as prescribedis important, but it is not the first action to take. Pain management is the priority immediately after surgery.
D. Apply ice to the stump for 60-90 minutes.
Applying ice to the stump for 60-90 minutesis not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
Full Explanation
The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.